Documentation in Pediatrics

CHAPTER 14


Documentation in Pediatrics


Lori Quinn and Agnes McConlogue



LEARNING OBJECTIVES


After reading this chapter and completing the exercises, the reader will be able to:


1. Describe the laws governing early intervention and school-based therapy in the United States.


2. Identify the key components of documentation in early intervention and school-based settings.


3. Create goals for the pediatric population based on best practice standards.


As a child progresses through the pediatric spectrum of service delivery, the documentation, evaluation, and implementation involved require a unique set of standards. The “pediatric patient” can refer to an individual from birth to 21 years of age. Consideration of the needs of the child and the family is paramount and must be incorporated into the evaluation and documentation process. Furthermore, pediatrics often involves multidisciplinary collaboration, perhaps even more so than in other patient populations. Pediatric documentation is read by a wide range of health and non-health professionals, thus requiring specific skills from the PT.



Purpose of Pediatric Evaluation


As with evaluations in other patient populations, PTs working with pediatric clients need to understand the primary purpose of their assessment to determine an overall assessment strategy. Four purposes of performing evaluations were presented in Chapter 2: descriptive, discriminative, predictive, and evaluative. A descriptive measure describes the child’s current state of functioning, problems, and needs (e.g., activities and impairments). This is typically done through documentation of the therapist’s observations and the results of any examination findings (e.g., range of motion, tone assessment), which is done for virtually every client. In addition to descriptive measures, therapists frequently incorporate standardized testing into their initial evaluation and documentation for a pediatric client, either for discriminative (e.g., does the child have a developmental delay?) or predictive (is the child at risk for developing a certain disability?) purposes. Finally, evaluative measures, which are measures used to show change over time, are used for children participating in ongoing intervention or to assess changes over a certain period.


The structure of an evaluation report for a pediatric client can look quite similar to other general physical therapy evaluations, including the reason for referral, description of participation, activities and any impairments, an assessment, goals, and plan of care. However, there are some important considerations for report writing and documentation for this population. These issues are discussed as they pertain to two broad categories of pediatric clients: early intervention (typically from birth to 3 years) and school-aged (3 to 21 years).



Early Intervention


IDEA


The Program for Infants and Toddlers with Disabilities, also commonly known as Part C of the Individuals with Disabilities Education Act (IDEA 2004), is a federal program offering assistance to states to “maintain and implement a statewide, comprehensive, coordinated, multidisciplinary, interagency system of early intervention services for infants and toddlers with disabilities and their families” (IDEA 2004, section 303.1 (a)). There is a clear focus on family involvement in the wording of IDEA 2004, throughout all phases of service delivery, most notably during the early intervention program (EIP). Part C of IDEA 2004 requires that children who meet the criteria receive services from birth until the child no longer requires them or when, typically, they reach their third birthday (Box 14-1).



BOX 14-1   IDEA, Part C


Under Part C of IDEA, states must provide services to any child who:




DETERMINING ELIGIBILITY


Aspects of eligibility for services, including physical therapy, differ from state to state because each state can use its discretion in determining the EIP. The provision of physical therapy is included among the related services to promote function and adaptation to the child’s natural environment, typically in the home. Individual states govern the specific eligibility criteria for developmental delay and at-risk children. Although the criteria for eligibility vary among states, most states require scores from standardized tests as the determinant of service implementation.


For example, a therapist may be called upon to report his or her findings in terms of percent delay or as standard deviations from the norm. For example, in certain states for a child to receive services there must be a 33% delay or 2 standard deviations from the mean in one functional area or 25% delay or 1.5 standard deviations from the mean in each of two functional areas. The percentage and standard deviations may differ according to individual state requirements. Therapists working in states that require specific criteria must therefore provide the results of standardized tests in their evaluation report, which will then be used to determine a child’s eligibility for early intervention services. Hawaii is currently an example of a state that does not require score reporting, relying instead on the recommendation of the multidisciplinary team (MDT), which typically includes a speech therapist, special educator, or an occupational therapist. In addition, individual states may provide their own definition of “developmental delay,” typically referring to the child who has not attained expected developmental milestones in one or more areas of development: cognitive, physical, communication, social/emotional, or adaptive.



FAMILY-CENTERED PLANNING


The focus on family-centered planning is an important component of the EIP. The ability to incorporate the family into a collaborative, team-based, problem-solving approach offers the maximal potential for success versus viewing the family and child as passive recipients of individual services. Based on current research and best practice standards, the early intervention therapist should include the following as part of the initial discussion with the family: their concerns, their expectations, the child’s strengths, and the family’s daily routine (Farrell et al., 2009). If the therapist is able to obtain this information before the assessment, he or she has a greater chance of capturing the child’s true abilities beyond the scope of standardized testing. In addition, each infant/toddler has uniquely different needs. By incorporating the family into the assessment process, the PT offers the child the security he or she needs to allow the PT to perform the best possible evaluation that is truly representative of the child and family.



DOCUMENTATION OF EARLY INTERVENTION EVALUATIONS


Evaluations serve “dual, sometimes competing functions: providing ecologically valid, functionally relevant information and evaluating eligibility for services through normative references” (Farrell et al., 2009). Early intervention evaluation reports are primarily read by individuals who are not health care professionals—most importantly, the child’s parents. Best practice in early intervention report writing involves several key components. The report should be free of jargon and easily interpreted by individuals outside the medical field (see Box 14-2 for more details on optimal report writing). If medical terminology is required, it should be defined whenever possible. Case Example 14-1 provides an example of a physical therapy evaluation for a young child being evaluated for early intervention services. As shown in this example, the headings for an early intervention evaluation can differ slightly from that typically written in a hospital or clinic setting but have the same general structure.



BOX 14-2   Strategies for Optimal Report Writing in Early Intervention




1. Provide parenthetical definitions.


    Joey was unable to maintain quadruped (on hands and knees) when placed there. While attempting to roll supine (on his back) to prone (on his stomach) he was observed to use an extensor pattern (use of primarily one muscle group) to complete the transition.


2. Explain test results in plain language.


    The scores on the standardized test of motor development indicate that Jane is currently performing at the 3rd percentile. This means that the majority of her age-related peers are functioning at a higher level and, based on parent report, scores, age equivalents, and discipline-specific assessment, Jane is eligible for early intervention services.


3. Describe concepts functionally.











Poor example Optimal example
Annie presented with moderate hypotonia of the trunk. Annie has a lower resting level of muscle stiffness than what is expected. This affects her posture and her ability to move against gravity with independence and efficiency.


4. Eliminate negative reporting.











Poor example Optimal example
Nikki was resistant to handling and refused to participate in the evaluation process. Nikki was self-directed in her play, preferring to follow her own agenda more exclusively than is typical for her age.


5. Avoid deficit-focused language.











Poor example Optimal example
Mark has only fair strength of his abdominals and is unable to get into sitting independently. Mark is able to maintain sitting when placed there. Strengthening his abdominal muscles to assist him in completing the transitions into and out of sitting will be a primary focus of physical therapy intervention.


6. Lead with the child’s competencies.











Poor example Optimal example
Sarina does not ascend/descend the stairs reciprocally. Sarina is able to climb a flight of stairs. She is emergent in her ability to climb up and down the stairs using the mature pattern (step-over-step) expected of her age.


7. Avoid “but/however” constructions.











Poor example Optimal example
Roberto can transition sit to stand but is unable to do it without help from his mother or holding onto the couch. Roberto is able to transition from sit to stand when he is provided with external support from an adult or a stable surface.


Adapted from Towle PO, Farrel AF, Vitalone-Raccaro N: Report writing in early intervention: guidelines for user-friendly, strength-based writing, Zero to Three, 28:53-60, 2008.



CASE EXAMPLE 14-1   Early Intervention Evaluation



Name: Jane Johnson  D.O.B.: 4/5/08  Date of Eval.: 10/15/09


Reason for Referral


(Typically includes reason for referral, location and time of evaluation and information about the child—who was present, behavior, and communication.)


Jane is an 18-month-old girl diagnosed with developmental delay. She has been referred for physical therapy evaluation secondary to concerns regarding her ability to access her environment independently. Her mother has made additional requests for evaluations in speech and occupational therapies.


Communication with the mother occurred prior to evaluation to determine Jane’s schedule and to plan the optimal time for evaluation, in addition to discussing Jane’s strengths/interests and the overall concerns of her family. Birth history was typical: Jane was born at term with no complications. Jane was evaluated in her home after her nap at 3 PM. Her mother and older brother, age 5, were present.




Activity/Participation


(Typically includes assessment of child’s ability to function within his or her natural environment.)




DEVELOPMENTAL POSITIONS/MOBILITY:


Jane is able to sit independently and manipulate (play with) toys on her lap. She will lean on one of her extended arms when reaching outside her base of support (contact with the ground or seating surface) and is able to successfully retrieve what she needs. She is able to keep her balance if challenged to the front or side but has difficulty when challenged to the back. Throughout the evaluation, Jane preferred ring sitting (knees bent with soles of the feet facing each other) on the floor and would quickly attempt to get back into that position. She achieves this by flexing (leaning) her trunk forward and pushing herself back over her pelvis (hips) with her upper extremities (arms).


Jane sleeps in a crib and has begun pulling to stand on the rails when she wakes up in the morning. She enjoys being carried around. Jane is able to creep on hands and knees for 2-3 consecutive cross-pattern advancements and with coaxing from her family. She prefers to scoot across the floor in a ring-sit position, utilizing her legs to pull herself, with her trunk flexed forward and her arms out for balance. She is able to get around quickly and was observed to move throughout the main floor of her home utilizing this pattern. She has difficulty climbing the stair; her mother reports Jane has a fear of falling and she prefers to carry her up and down.


Jane was observed to pull up to stand utilizing the couch for support. She is able to stand with upper extremity support and will hold on with alternating (right or left) upper extremities to reach for a toy but is resistant to standing independently. She enjoys taking 4-5 steps with her push toy and is recently able to take a few steps when an adult holds her hands out to the sides.



ACTIVITIES OF DAILY LIVING:




1. Feeding. Jane utilizes a bottle, which she is able to hold independently when propped into a reclining position. She is able to eat small finger foods and is reported to be a “fussy eater”—eating only certain pureed foods. She enjoys being with her family at mealtime and is starting to attempt to feed herself with a spoon. She utilizes a highchair during mealtime and certain play activities. Her seated posture is an area of concern for the family as she consistently “slumps” to the side and is unable to stay upright despite attempts at supporting her position.


2. Bathing. This is reported as an area of difficulty for the family as she does not enjoy the bath and requires support to maintain safe positioning.


3. Dressing. Jane enjoys removing her socks and attempts to remove her shoes by pulling at the Velcro straps. She is compliant in allowing her mother to dress and undress her.


4. Play. She is involved in an organized playgroup and her mother reports that she has great difficulty keeping up with her peers. She enjoys the songs and will attempt to pop bubbles, roll the ball, and will clap at the end of each class. She is currently the only one in her class who is not walking yet. In the playground, Jane enjoys the infant swing as her primary mode of play. She enjoys playing with her brother and despite the age difference, they are reported to play well together. She enjoys looking at books and will attempt to do simple shape puzzles. Her favorite doll, which is also a small blanket, is generally required as a comforting object.


5. Transitions. Jane is carried throughout the day for all transitions. She utilizes a stroller during family walks/outdoor transportation. Her mother reports that when she is food shopping, she has a difficult time keeping her daughter upright in the seat of the shopping cart and has devised a plan where she props her up in the cart itself, with Jane looking forward, and that this seems to work best for them.



Impairments (Musculoskeletal Assessment)




1. Strength. There is sufficient strength of the upper and lower extremities to support her body weight in stance (standing) and while maintaining a sitting posture over an extended arm. She is able to complete a pull to sit with head lag noted (she has difficulty keeping her head in the center, with her chin tucked during an assisted sit-up; children of her age are expected to complete this activity without a head lag). She is able to roll independently to alternate sides. She is able to lift toys of moderate load (estimated to weigh 10% of her body weight) and is able to bang, throw, and squeeze a variety of toys and balls. There is evidence of emergent strength of the lower extremities as she pulls to stand through half-kneel (one leg with the foot flat, the other on the knee) and is able to take some steps when given support.


2. Range of Motion. There is full range of motion throughout the joints of the upper and lower extremities.


3. Tone. (Tone refers to the resting level of muscle stiffness that allows our bodies to efficiently initiate movements and to support those movements against gravity with ease.) Jane exhibits generalized hypotonia (lower resting level of muscle stiffness than is expected at this age). This is notable for the trunk musculature, primarily the abdominal (stomach) muscles.


4. Balance. Static (stationary) balance is categorized as follows: She is able to maintain her balance in positions where her base of support is wide (body contact to surface support is large). When static balance is tested in positions against gravity (kneeling, standing), she has greater difficulty and frequent loss of balance. Dynamic balance (with movement) is an area of difficulty for Jane at this time with loss of balance noted when challenged outside her base of support.


5. Alignment/Posture. Jane has difficulty in utilizing a variety of efficient postures to access her environment. While seated in ring-sit, Jane exhibits rounded shoulders, a forward head posture (head not in line with shoulders), and a rounded back. While standing, Jane’s legs are in a wide base of support and her feet are significantly pronated (flat), more than what is expected at her age.



Standardized Assessments


(These are tests that measure a child’s performance on certain tasks to that of their peers or as specific levels for individual task performance)


The following standardized assessments were used:



1. Alberta Infant Motor Scale. The scores indicate that Jane is currently performing below the 5th percentile. This means that, currently, the majority of her age-related peers are functioning at a higher level.


2. Pediatric Evaluation of Disability Inventory. Scored as follows: Self Care: 40.4, Mobility: 20.3, and Social Function: 50.8. (Reported as Normative Standard Scores for Functional Skills, which allows comparison to peers with the mean (average) score set at 50 and a standard deviation of 10. Children are expected to function within 2 standard deviations of the mean. Therefore, a range of functional skill scores between 30 and 70 is expected.) This indicates that Jane has delays in development compared with her peers and, in particular, exhibits the greatest difficulty in the category of Mobility.

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Related posts:

Documenting Reason for Referral: Participation and Social History, Legal Aspects of Documentation Treatment Notes and Progress Notes Using a Modified SOAP Format Essentials of Documentation Documenting Impairments in Body Structure and Function Documenting Goals

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Jun 22, 2016 | Posted by in PHYSICAL MEDICINE & REHABILITATION | Comments Off on Documentation in Pediatrics

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